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Interim Designation of Agent to Receive Notification of Claimed Infringement

Basic fee of $105 covers indexing of this one name.

Additional $35 per group of 10 or fewer.

Full Legal Name of Service Provider: ______________________________________ ______________________________________________________________________ Alternative Name(s) of Service Provider (including all names under which the service provider is doing business):_______________________________________________ ______________________________________________________________________ ______________________________________________________________________ Address of Service Provider:_______________________________________________ Name of Agent Designated to Receive Notification of Claimed Infringement:______________________________________ Full Address of Designated Agent to which Notification Should be Sent (a P.O. Box or similar designation is not acceptable except where it is the only address that can be used in the geographic location): _________________________________________________________________________________________ _________________________________________________________________________________________

Telephone Number of Designated Agent:___________________________________ Facsimile Number of Designated Agent:____________________________________ Email Address of Designated Agent:_______________________________________ Signature of Officer or Representative of the Designating Service Provider: ______________________________________ Date:__________________________ Typed or Printed Name and Title: __________________________________________ _____________________________________________________________________ Note: This Interim Designation Must be Accompanied by a Filing Fee* Made Payable to the Register of Copyrights. *Note: Current and adjusted fees are available on the Copyright website at Mail the form to: U.S. Copyright Office, Designated Agents P.O. Box 71537 Washington, DC 20024-1537

The DMCA Toolkit